Objectives: To obtain reliable estimates of the effects of neuraxial blockade with epidural or spinal anaesthesia on postoperative morbidity and mortality. Design: Systematic review of all trials with randomisation to intraoperative neuraxial blockade or not. Studies: 141 trials including 9559 patients for which data were available before 1 January 1997. Trials were eligible irrespective of their primary aims, concomitant use of general anaesthesia, publication status, or language. Trials were identified by extensive search methods, and substantial amounts of data were obtained or confirmed by correspondence with trialists. Main outcome measures: All cause mortality, deep vein thrombosis, pulmonary embolism, myocardial infarction, transfusion requirements, pneumonia, other infections, respiratory depression, and renal failure. Results: Overall mortality was reduced by about a third in patients allocated to neuraxial blockade (103 deaths/4871 patients versus 144/4688 patients, odds ratio=0.70, 95% confidence interval 0.54 to 0.90, P=0.006). Neuraxial blockade reduced the odds of deep vein thrombosis by 44%, pulmonary embolism by 55%, transfusion requirements by 50%, pneumonia by 39%, and respiratory depression by 59% (all P Conclusions: Neuraxial blockade reduces postoperative mortality and other serious complications. The size of some of these benefits remains uncertain, and further research is required to determine whether these effects are due solely to benefits of neuraxial blockade or partly to avoidance of general anaesthesia. Nevertheless, these findings support more widespread use of neuraxial blockade.

/pdf/reduction-of-postoperative-mortality-and-morbidity-with-1uuz7uqkyl.pdf

Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials.

More and more systematic reviews of diagnostic test accuracy studies are being published, but they can be methodologically challenging. In this paper, the authors present some of the recent developments in the methodology for conducting systematic reviews of diagnostic test accuracy studies. Restrictive electronic search filters are discouraged, as is the use of summary quality scores. Methods for meta-analysis should take into account the paired nature of the estimates and their dependence on threshold. Authors of these reviews are advised to use the hierarchical summary receiver-operating characteristic or the bivariate model for the data analysis. Challenges that remain are the poor reporting of original diagnostic test accuracy studies and difficulties with the interpretation of the results of diagnostic test accuracy research.

/pdf/systematic-reviews-of-diagnostic-test-accuracy-2d30ufere3.pdf

Systematic Reviews of Diagnostic Test Accuracy

In 2009, the American Cancer Society (ACS) Prostate Cancer Advisory Committee began the process of a complete update of recommendations for early prostate cancer detection. A series of systematic evidence reviews was conducted focusing on evidence related to the early detection of prostate cancer, test performance, harms of therapy for localized prostate cancer, and shared and informed decision making in prostate cancer screening. The results of the systematic reviews were evaluated by the ACS Prostate Cancer Advisory Committee, and deliberations about the evidence occurred at committee meetings and during conference calls. On the basis of the evidence and a consensus process, the Prostate Cancer Advisory Committee developed the guideline, and a writing committee drafted a guideline document that was circulated to the entire committee for review and revision. The document was then circulated to peer reviewers for feedback, and finally to the ACS Mission Outcomes Committee and the ACS Board of Directors for approval. The ACS recommends that asymptomatic men who have at least a 10-year life expectancy have an opportunity to make an informed decision with their health care provider about screening for prostate cancer after they receive information about the uncertainties, risks, and potential benefits associated with prostate cancer screening. Prostate cancer screening should not occur without an informed decision-making process. Men at average risk should receive this information beginning at age 50 years. Men in higher risk groups should receive this information before age 50 years. Men should either receive this information directly from their health care providers or be referred to reliable and culturally appropriate sources. Patient decision aids are helpful in preparing men to make a decision whether to be tested.

https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.3322/caac.20066

American Cancer Society Guideline for the Early Detection of Prostate Cancer: Update 2010

https://www.europeanurology.com/article/S0302-2838(13)00558-7/pdf/Systematic+Review+of+Complications+of+Prostate+Biopsy

Systematic review of complications of prostate biopsy.

Spinal epidural abscess (SEA) was first described in the medical literature in 1761 and represents a severe, generally pyogenic infection of the epidural space requiring emergent neurosurgical intervention to avoid permanent neurologic deficits. Spinal epidural abscess comprises 0.2 to 2 cases per 10,000 hospital admissions. This review intends to offer detailed evaluation and a comprehensive meta-analysis of the international literature on SEA between 1954 and 1997, especially of patients who developed it following anesthetic procedures in the spinal canal. In this period, 915 cases of SEA were published. This review is the most comprehensive literature analysis on SEA to date. Most cases of SEA occur in patients aged 30 to 60 years, but the youngest patient was only 10 days old and the oldest was 87. The ratio of men to women was 1:0.56. The most common risk factor was diabetes mellitus, followed by trauma, intravenous drug abuse, and alcoholism. Epidural anesthesia or analgesia had been performed in 5.5% of the patients with SEA. Skin abscesses and furuncles were the most common source of infection. Of the patients, 71% had back pain as the initial symptom and 66% had fever. The second stage of radicular irritation is followed by the third stage, with beginning neurological deficit including muscle weakness and sphincter incontinence as well as sensory deficits. Paralysis (the fourth stage) affected only 34% of the patients. The average leukocyte count was 15,700/µl (range 1,500–42,000/µl), and the average erythrocyte sedimentation rate was 77 mm in the first hour (range 2–50 mm). Spinal epidural abscess is primarily a bacterial infection, and the gram-positive Staphylococcus aureus is its most common causative agent. This is true also for patients who develop SEA following spinal anesthetics. Magnetic resonance imaging (MRI) displays the greatest diagnostic accuracy and is the method of first choice in the diagnostic process. Myelography, commonly used previously to diagnose SEA, is no longer recommended. Lumbar puncture to determine cerebrospinal fluid protein concentrations is not needed for diagnosis and entails the risk of spreading bacteria into the subarachnoid space with consequent meningitis; therefore, it should not be performed. The therapeutic method of choice is laminectomy combined with antibiotics. Conservative treatment alone is justifiable only for specific indications. Laminotomy is a therapeutic alternative for children. The mortality of SEA dropped from 34% in the period of 1954–1960 to 15% in 1991–1997. At the beginning of the twentieth century, almost all patients with SEA died. Parallel to improvements in the mortality rate, today more patients experience complete recovery from SEA. The prognosis of patients who develop SEA following epidural anesthesia or analgesia is not better than that of patients with noniatrogenic SEA, and the mortality rate is also comparable. The essential problem of SEA lies in the necessity of early diagnosis, because only timely treatment is able to avoid or reduce permanent neurologic deficits.

Spinal epidural abscess: a meta-analysis of 915 patients.

Comparison of screening methods in the detection of bladder cancer

Serious neurologic complications rarely occur after spinal anesthesia. Historically, the reported frequency of persistent sensory or motor deficits has ranged from 0.005% to 0.7%. However, the introduction of small-gauge needles and new local anesthetics and intrathecal adjuvants makes it necessary to reevaluate the frequency of neurologic complications after spinal anesthesia. This study is a retrospective review of 4767 consecutive spinal anesthetics performed between June 1987 and June 1990. Mean patients age was 65 +/- 15 yrs. There were 3560 (74.7%) men and 1207 (25.3%) women. A preexisting neurologic condition was present in 481 (10.1%) cases. The surgical procedures were genitourinary and lower extremity orthopedic in 4348 (91.2%) cases. A paresthesia was elicited during needle placement in 298 (6.3%) cases. Six patients reported pain upon resolution of the spinal anesthetic (persistent paresthesia). Four persistent paresthesias resolved within 1 wk; the remaining two resolved in 18-24 mo. The presence of a paresthesia during needle placement significantly increased the risk of persistent paresthesia (P < 0.001). There, were also two infectious complications. One patient with recent (treated) urosepsis underwent a urologic procedure under spinal anesthesia and subsequently developed a disc space infection. The second patient developed a paraspinal abscess. Both were treated with surgical drainage and antibiotics and remained neurologically intact. There were 62 (1.3%) patients with a postdural puncture headache, including 23 (0.5%) who underwent an epidural blood patch. These results are similar to those of previously published reviews and demonstrate the continued safety of spinal anesthesia.

A retrospective review of 4767 consecutive spinal anesthetics: central nervous system complications. Perioperative Outcomes Group.

Recent case reports of cauda equina syndrome after continuous spinal anesthesia have led to a reevaluation of the indications and applications of this regional anesthetic technique. However, few large studies have formally investigated the frequency of neurologic complications using macro- and microcatheter (smaller than 24 gauge) techniques. This retrospective review examines 603 continuous spinal anesthetics, including 127 administered through a 28-gauge microcatheter, performed between June 1987 and May 1992. The surgical procedure was orthopedic in 397 of 476 (83.4%) macrocatheter patients. All microcatheter patients were parturients. Three patients reported pain (persistent paresthesia) postoperatively. In two patients, the symptoms resolved in 4 days; the other patient was discharged 8 days postoperatively with residual foot pain. There was also one patient with aseptic meningitis and one patient with a sensory cauda equina syndrome (still present after 15 mo). There were 58 (9.6%) patients with a postdural puncture headache (PDPH), including 42 of 127 (33.1%) patients in the microcatheter group. An epidural blood patch was performed in 41 (6.8%) patients. The frequency of neurologic complications, excluding PDPH, is similar to those in published reviews. However, PDPH in microcatheter patients is more frequent than previously reported.

Neurologic Complications of 603 Consecutive Continuous Spinal Anesthetics Using Macrocatheter and Microcatheter Techniques

Trends and risk factors for prostate biopsy complications in the pre-PSA and PSA eras, 1980 to 1997.

COMPARISON OF URINARY CYTOLOGY, BTA stat, NMP22, FDP, TELOMERASE, CHEMILUMINESCENT HEMOGLOBIN AND THE HEMOGLOBIN DIPSTICK IN THE DETECTION OF BLADDER CANCER

Jennifer A. Besse

Papers

Comparison of screening methods in the detection of bladder cancer

A retrospective review of 4767 consecutive spinal anesthetics: central nervous system complications. Perioperative Outcomes Group.

Neurologic Complications of 603 Consecutive Continuous Spinal Anesthetics Using Macrocatheter and Microcatheter Techniques

Trends and risk factors for prostate biopsy complications in the pre-PSA and PSA eras, 1980 to 1997.

COMPARISON OF URINARY CYTOLOGY, BTA stat, NMP22, FDP, TELOMERASE, CHEMILUMINESCENT HEMOGLOBIN AND THE HEMOGLOBIN DIPSTICK IN THE DETECTION OF BLADDER CANCER